H&P Issues

[Squirmish]

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The attendings at the clinic that I'm doing my current rotation at will not allow us to type into the patients' computer charts/records. Instead, they make us write on these blank pieces of paper that have HPI, PSH, PMH, etc. labelled on them. We're supposed to take these forms into the rooms, take a history, and do a physical and record all of our findings on those forms and turn them in to the attending once we leave the room.

I've been getting **** from attendings that my HPIs suck. They keep telling me that it needs to be like a story. I know how to write a H&P and an HPI but it's so hard to do it on paper. If I can go type it all out on a computer and edit it, then I'm fine. But if I have to turn in my original hardcopy, then I have problems. The patients' stories are always all over the place and never sequential. When I'm interviewing the pt, I do my best to write everything in a sequential matter, but it's so hard especially when the pt forgets something until the very end. ARGH! We're not allowed to rewrite our HPI so I need to get it perfectly when I'm in the room with the pt.

Does anyone have any advice for me? This is so frustrating.

 

[JAR]

Can you wait until you leave the room or the patient leaves the room and write your notes then? It is often easier to write the 'story' after you have the whole picture as opposed to bits and pieces as the patient says them.

 

[agranulocytosis]

Agree with the above. Don't write on the H&P form as you're interviewing the patient...instead write your notes down on a separate piece of paper (like your notepad) then use those notes to formulate a well-thought out HPI.

 

[Squirmish]

We've already gotten "in trouble" for writing on notepads. They want everything that we write to be on that form. Yes, they do observe and monitor what we're writing on when we're doing an H&P in the exam room. I personally think it's dumb because that's not how it's done everywhere else. They say it's the best way for us to learn, but I disagree. The attendings also said that they will be basing most of our grades on the quality of our H&Ps so I can't blow this off.

😡

 

[scootad.]

Since they don't let you write out your H & P outside of the room (which I find patently absurd, btw), then why don't you talk to the patient, get the whole story from them and when you are finished getting the history, tell the patient to excuse you for a few minutes... "Give me 5 minutes so I can write out everything that you told me"...then write out the H & P. That way if you find you have any questions or gaps in the story that need explaining they are right there in the room with you and you can ask them.

It can be difficult to write and listen at the same time, so first listen, then after they are done talking, then write.

 

[jbp100]

Rookie mistake...

I remember starting out on medicine and going to admit people and trying to follow their incoherent story as they told it on pen and paper. Going back and reviewing those notes before presenting to the resident or the attending I thought, what was I thinking!

Soon after that I embraced the method as above of trying to just talk to the patient and then pulling everything together after the fact. I noticed that I may even right down some pertinent positives from the review of systems or the physical exam and then plug those in to my default note after the fact.

Or in your case, just writing the note after the encounter while still in the room will help. I have done this before. In these cases I tell the patient that I am just jotting down some notes of what we had talked about. It also gives them the opportunity to bring up things they may have forgotten while you both sit there in silence! 🙂

 

[OncoCaP]

Although we are always told to write the patient's story, some attendings/residents will crush you if you write down one of those rambling twisted tales. My suggestion is to listen to the patient and then piece together a brief & simplified medical description of what has been going on with that patient ... it needs to pull together everything the patient and collateral said in a neat leading package. Hit the high points of the diagnostic considerations that you are going to have in your assessment (setting up your problem list/DDx and assessment later on) and very briefly mention the rest.

The HPI winds up being your interpretation of what the patient presented with all the confusing parts, rabbit trails, confabulations, and disorganization set aside as brief footnotes unless those are part of your medical workup. Personally, I just listen to the patient and then write the thing if it's not too long. You do want to capture the essence what the patient said. You need to state what you know clearly from the history and briefly identify areas that may be unclear or conflicting. Indicate if the patient has difficulty recalling certain key facts or explaining him/herself clearly.

If I needed to write the H&P while I'm meeting with the patient (as when taking a long psych hx, for example), I would ask him/her some small-talk questions about food she likes or where he met his girlfriend or where the best place to buy a beach umbrella is while I'm furiously writing down a key piece of history. If the patient is comfortable, s/he might even just tell you some key facts that unlock the mystery of their illness. Before (or near the beginning of) the interview you might try to lay out the basic structure of your H&P document headings as you get started. By now you probably know long each section is going to be for a given patient. Then just "fill in the blanks" so to speak. You might start with open questions and then get very specific, perhaps even to the point of yes or no questions.

As the patient skips around, you skip around in your document to the relevant section ... she starts talking about how she and her boyfriend smoke this that or the other, and you are in Social Hx. He covers summary items, and now you restate those in a descriptive way near the top of the HPI, essentially telling the reader what is going on ("... and when I slipped cutting the hedge with my chainsaw, the blade came down and cut the top of my thumb off ..." becomes "On day of admission, patient was gardening with a chainsaw and accidentally severed the distal ~1 cm of his left thumb ..." "Your HPI might start with summary sentence or two that sets the stage for what the basic problem is and then you have a little section for each aspect of what's bothering the patient. This helps you remember to get the pertinent "story" details for each problem (diarrhea, depression, URI, etc.). Your attending might want the summary at the end rather than the beginning of the HPI, but at some point, you need to tell your reader the key facts for the 1st diagnosis. You really don't want to provide a transcript of what the patient said, but key quotes can be helpful & appropriate. You want to write sections with a chronology in mind, but if you are writing an original during the interview, you may not be able to preserve the chronology if the patient skips around and you are required to write your H&P as you take it.

You will learn how to write what your attending/residents want ... however, try to get it down as quickly as possible to maximize your grade. You might even want to practice by writing an H&P for a character in a movie or TV show (even a video game, for that matter). Being able to write a quick & accurate note or H&P without needing a wordprocessor to edit is a basic skill that we all need to learn as part of training. You aren't always going to have a computer to enter your record on. Each service and attending/resident has his or her peculiar requirements -- be sensitive to those.

 

[plainolerichie]

One thing that kinda helped me was to state a patient's story as if I'm trying to present a specific diagnosis. You won't include all the crap the patients say, but only what is relevant from when they told you.

 

[45408]

Many patients' stories are completely inaccurate. When you actually talk to family or look at old records, you'll find out that they were totally wrong. That is not an HPI, that's an CHPI (confabulated history of presenting illness).

It's like the old lady who came in with "these new wounds on her legs." Long story short (as far as we can tell, since she had a huge lapse in care), she had long-standing untreated HTN --> A-fib --> CHF --> peripheral edema/poor circulation --> ulcerations --> wound infection. The history she originally gave would lead you so far of the actual mark that it was unbelievable. When I talked with the daughter and asked probing questions ("So did you notice that her shoes weren't fitting any more?" Oh yeah, now that you mention it! "Was she getting short of breath?" Well, her lips turn blue when she walks into the grocery store), I finally got the real deal.

 

[alwaysaangel]

We've already gotten "in trouble" for writing on notepads. They want everything that we write to be on that form. Yes, they do observe and monitor what we're writing on when we're doing an H&P in the exam room. I personally think it's dumb because that's not how it's done everywhere else. They say it's the best way for us to learn, but I disagree. The attendings also said that they will be basing most of our grades on the quality of our H&Ps so I can't blow this off.

😡

You say they make sure that you don't write on notepads but do you really have to write anything while in the room? Why can't you write it after?

Its not really bad that they make you write it instead of type it since the majority of clinics/hospitals don't yet have computerized medical records and it would kind of suck to get to internship and not have a clue how to write a note without the ability to edit in a computer.

But I can't believe they force you to write the entire note in front of the patient - seems pretty unprofessional.

I jot down big things I think I'll forget - with room for what else I have to write in between. Then I'll jot down big physical findings and fill in everything else including the A/P after the fact. However, this is for FM so its not that much info and the note isn't that expansive most of the time so this method may be more difficult in an inpatient setting.

 

[cpants]

Where do you go to school? That is the stupidest way to learn to write an h/p I've ever heard. I would forget the story approach and go with the outline approach as soon as you get off this rotation. And I've never even heard of writing it in the room. Why? Doesn't it make more sense to go outside where you can think about what you just learned from the h/p, look over labs and imaging, and actually come up with a dx and plan?

 

[Doctor Bob]

At the end of your HPI, add "and the patient lived happily ever after". All stories need a good ending.

 

[TMP-SMX]

And you should start with once upon a time. Don't start with patient identifiers.

 

[metallo]

The patients' stories are always all over the place and never sequential. When I'm interviewing the pt, I do my best to write everything in a sequential matter, but it's so hard especially when the pt forgets something until the very end. ARGH! We're not allowed to rewrite our HPI so I need to get it perfectly when I'm in the room with the pt.

About a week ago, a senior resident on my rotation gave me some very good advice. When you start taking a history (after you ascertain why the patient is there), ask them when the last time was they were completely healthy (usually x number of days/weeks). Or, in the case of a patient with multiple chronic medical problems, ask when was the last time they didn't have their current issue. Now you have your starting point. You can then ask history questions in a sequential manner. Ask something like, "OK, what happened next?" You can even explain to the patient that you'd like to go in order. Most patients will probably leave something out that you'll have to add in later, but I do think it's a good idea to start at the beginning and try to go in order... it's so much easier than trying to piece everything together later. If you're the first one seeing the patient for a full H&P, you should be doing a separate Review of Systems at the end that will pick up the things you missed anyway. As you get more efficient, you'll know the types of questions that you need to move up to the HPI from the ROS and you'll miss less info early in your history.